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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9�d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Lpplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Ind/or install the work herein described. This application is made in compliance with San Jonquil <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATIONtQV 'l/ / � 1 ' �; CENSUS TRACT <br /> owner's Name (f S4��Alf 4 -S0N-S Phone <br /> Adress P ® Z(�Z_3 City jQ,(f—j`aAl <br /> ontractor's NameI,'-,IZ License #J z- Phone <br /> YPE OF WORK (Check) : NEW WELL =4' DEEPEN /_/ RECONDITION /_� DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (b <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 4 <br /> Domestic/public Driven Gauge of Casing tz <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �_ Rotary Type of Grout �,(.f,l; <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> JMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> JMP REPLACEMENT: / / State Work Done <br /> JMP .REPAIR: / / State Work Done <br /> :SiRUCTION OF WELL: Well Diameter Approximate Depth <br /> 0 <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> -ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ,LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> iformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> .IOR TO G TING ANb A I AL I ECTION. <br /> :GNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE - <br /> FOR DEPARTMENT USE ONLY <br /> IASE I <br /> 'PLICATION ACCEPTED BY DATE <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PmSkAWFINAL INSP CTION <br /> fSPECTION BY INSPECTION BY DATE <br /> b/ <br /> V v line . 1 ,177 '7M <br />